If the Patient Gets Stuck, Know Where to Turn - The Emergency Medical Minute

If the patient gets stuck, know where to turn

Chief Complaint:

Left hand pain and swelling

HPI:

73 year-old right hand dominant female presents about 6 hours after accidentally self-injecting her left hand with about 2 mL of bovine viral vaccine (most of the vaccine got into the cow but when it moved she slipped). She states that the pain was initially localized and mild at the site of injection but has increased in intensity from moderate to severe in nature and throbbing sensation. It is moving towards the distal forearm. She states that she has tried Epsom salt soaks as well as milking the arm from proximal to distal towards the injection site without any improvement in symptoms. She denies any numbness or tingling. No discharge from the site. Nothing like this has happened before.

Past medical surgical and social are not contributory

Pertinent Exam Findings:

General Appearance: Mild acute distress secondary to pain and anxiety.
Cardiovascular: Tachycardic and regular rhythm, radial pulse 2 out of 4, brisk cap refill.
Musculoskeletal:

    • Left hand: There is swelling over the thenar eminence, but the compartment is not tense. Severe tenderness over thenar eminence. Hand/wrist/fingers are held in normal resting position. No foreign body was seen on exam. Normal light touch of all fingers. The left wrist has full range of motion.
    • Flexor tendons: Full active/passive range of motion, and normal flexion of all superficialis/profundus tendons against resistance.
    • Extensor tendons: Full active/passive range of motion and normal extension of all superficialis/profundus tendons against resistance.

Skin: There is a 0.25 cm puncture wound approximately central area of the thenar eminence of the left hand. There is surrounding erythema that extends to the wrist proximally and distally up towards the index finger. The erythema wraps through the webbing between the thumb and index finger and over to the dorsum of the hand overlying the thumb and extending towards the index finger. There is no streaking, drainage or crepitus.
Neurological: Sensation intact light touch for radial, ulnar, median nerve.

Data Interpretation:

EKG: Sinus tachycardia otherwise unremarkable.
CBC, BMP, Lactic Acid, CK all normal.

ED Course:

Hand was consulted. They recommended taking the patient to the OR for complete washout. However, the patient refused to go to the OR. The patient had bedside local anesthesia as well as IV pain medication and the orthopedist performed bedside washout.



DISCUSSION:

Background:

Bovi-Shield GOLD 5 is used for the vaccination of healthy cattle as an aid to prevent infectious bovine rhinotracheitis caused by bovine rhinotracheitis virus, diarrhea caused by bovine viruses Types 1 and 2, parainfluenza virus, and bovine respiratory syncytial virus. Bovi-Shield GOLD 5 is a freeze-dried preparation of the modified live virus strains listed above, in addition to a sterile diluent used to rehydrate the freeze-dried vaccine. According to the products Material and Safety Data Sheet (MSDS), accidental human injection can cause serious local reactions. The oil-based nature of the vaccine causes inflammation which can lead to compartment syndrome in severe cases. Similar to pressure injection injuries with benign appearing entry wounds, there can be extensive soft tissue damage and high risk for infection.

Self-injection of veterinary vaccines is an occupational hazard for farmers and veterinarians. Needle stick injuries were reported to occur with a 1 in 1000 case frequency according to a survey of veterinarians. In approximately 17% of cases the site of accidental injection was the hand, as in our case. It is important for healthcare providers to maintain a high index of suspicion when treating injections of chemical substances and refer to the Material Safety Data Sheet as there can be significant complications from injections such as compartment syndrome.

Diagnosis:

Any workplace substance that can be considered hazardous requires a MSDS. These forms, required by the Occupational Health and Safety Administration (OSHA), contain information about the physical properties of hazardous substances allowing for risk assessment and safe use. In the case of accidental bovine vaccine injection, MSDS sheets can be accessed following a quick internet search of one of the many online databases or on the product’s website. Another resource for healthcare providers is the local poison control center which can quickly provide details about the substance, possible sequelae, and suggested treatment. Considering the difficulty of keeping track of all the ingredients in each substance used commercial chemicals, these are invaluable and life-saving resources that all medical professionals should be aware of. Benign appearing needle stick injuries may not result in an immediate sequelae of symptoms, resulting in a late presentation of serious symptoms and a delay in treatment. Signs of ischemia or local neural involvement are often the concerning symptoms that bring patients in within hours. For oil-based injections, severe acute swelling may result in compartment syndrome.

Management in ED:

Needle stick injuries from veterinary vaccines should be evaluated immediately by a physician. In most cases a surgical specialist should be consulted to consider washout. For compartment syndrome, prompt release of the pressure within the myofascial compartment or fasciotomy is the definitive treatment for compartment syndrome. It is also important to assess for a systemic allergic reaction or a superimposed infection depending on time of presentation.

Prognosis:

Time from the onset of injury to definitive treatment is the major determinant of prognosis. The quantity of foreign substance injected is an additional consideration for patient outcomes. Additionally, oil-based vaccination injuries have been associated with granulomatous reactions that may become chronic in nature, leading to the need for repeated debridement. Knowledge of the nature and quantity of the injection should guide the physician to obtain a surgical consult as soon as possible despite a benign-appearing wound, preventing the potential of amputation and other serious complications.

Differential Diagnoses:

Severe consequences of untreated puncture wounds include localized allergic reaction, anaphylactic reaction, compartment syndrome, and secondary infection.

Clinical Pearls:

    • Workplace substances will have a Material Safety Data Sheets and are widely available online either through the product website or online database
    • Oil-based vaccines can result in compartment syndrome in severe cases
    • Early surgical consult maybe warranted for fasciotomy or surgical washout

References:

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  4. Konstantakos et al 2007 Am Surg
    Diagnosis and management of extremity compartment syndromes: an orthopaedic perspective
    Nelson JA. Compartment pressure measurements have poor specificity for compartment syndrome in the traumatized limb. J Emerg Med. 2013 May;44(5):1039-44.
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Authors

Aaron Wolfe, DO, FACEP

Josh Bridges, MSIII

Sarah Rokhlin, MSII

 

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